Dr. Robert K. Ross, President and CEO of the California Endowment, is celebrated for his contributions as an outgoing Covered CA Board member, along with Kim Belshe and Susan Kennedy, at a post-board meeting reception.

Cost Sharing on Specialty Prescription Drugs

The most contentious issue at the Covered California board meeting was the one that was postponed, on how to design cost-sharing for certain high-cost medications. Covered California has been exploring opportunities to help consumers access expensive specialty drugs that are usually placed on the fourth tier of a pharmacy benefit formulary. Specialty drugs treat conditions such as HIV/AIDS, Hepatitis C, MS, and rheumatoid arthritis. The cost-sharing for some of these drugs can force consumers to shoulder the burden of spending the equivalent of their annual out-of-pocket maximum ($6350) for a single month’s prescription for a single drug.

Health Access was part of Covered California’s Specialty Drug Workgroup, which explored how drug benefit design impacts consumer access to specialty drugs and adherence with drug regimens. The workgroup helped to inform Covered California’s approach to addressing issues around affordability and access. As a result, the Covered California Board, at its March meeting, adopted policy changes improving the transparency of drug formularies and requiring the placement of some high cost drugs on lower benefit tiers. These changes offer improvements for consumers, but advocates are still concerned about the high cost-sharing for these drugs.

Why is cost-sharing for specialty drugs important to consumers? Almost 90% of individuals and families enrolled in Covered California are below 400% FPL ($48,000 for a single individual or $97,000 for a family of four). Asking Californians living on such modest incomes to spend hundreds or even thousands of dollars in a single month for medication is untenable. An ample body of peer-reviewed literature on medication adherence confirms what common sense already told us: if cost sharing is too high, patients will not fill the prescription, they will will skip doses, they will cut pills in half, or otherwise fail to take their prescriptions as prescribed.

A cap, but how much? Instituting a cap on the cost-sharing for specialty drugs can help consumers to manage these high costs and access the drugs they need. In considering a cap, Covered California is trying to balance helping consumers get the right care without undue financial barriers for those with particular health conditions while assuring overall affordability of health premiums (especially given that drug costs are expected to become a larger component of the total cost of health care.)

Covered California staff initially recommended placing a $500 cap on cost-sharing for specialty drugs on most metal tiers ($200 cap for platinum tier, recognizing that consumers pay higher premiums for the platinum tier, and for the low-income Silver tier). Health Access and other consumer advocates support having a cap, but believe $500 per prescription is too high for low- and middle-income consumers. A letter of six consumer groups made that case earlier this week, as did another letter by Insurance Commissioner Dave Jones. Covered California will continue exploring whether a lower cap can be instituted and we hope the Board will be able to take action at its May meeting.

Special Enrollment update

Covered California’s open enrollment period ended on February 15. We are now in the Special Enrollment Period (SEP), which allows people to enroll off season if they meet qualifying criteria such as marriage, loss of insurance, birth, and income changes that result in the loss of other coverage. For consumers who did not realize there was a tax penalty in 2014 or learned they may face a penalty in 2015, there is a limited-time only qualifying event to allow these consumers to enroll in Covered California by April 30, 2015. Consumers are always able to apply for Medi-Cal throughout the year. For more information about special enrollment and the full list of qualifying life events, visit the Covered California website at: www.coveredca.com/individuals-andfamilies/getting-covered/special-enrollment

From February 23-April 12, close to 75,000 people enrolled through special enrollment. Of these individuals, 25,000 enrolled due to losing Medi-Cal coverage, and 22,000 enrolled because of a qualifying life event.

1095-A Update

1095-A forms are reports that Covered California sends to consumers summarizing the subsidies they received through Covered CA. These forms are needed to file taxes. Some of the 1095-A forms sent to consumers were incorrect, so Covered California sent revised/corrected forms. Because this is the first year taxpayers are required to disclose whether they have health coverage and report subsidies received on their federal tax forms, the IRS is allowing, but not requiring, consumers to amend their taxes if doing so works to their benefit.

2015 Quality Rating System (QRS) Update

Jeff Rideout, Covered California’s Senior Medical Advisory, gave an update on their quality rating system. Covered California has worked to provide transparency not just on price, but also on quality, so consumers can make choices based on both cost and quality.

The federal government will produce a quality rating system in 2016. Covered California has been posting minimal quality data the past couple years, from the basic Consumer Assessment of Healthcare Providers and Systems survey of consumers (CAHPS). The CAHPS survey measures consumer satisfaction with access to care (getting needed care, getting needed care quickly), doctors and care (rating of all health care, personal doctor, and specialist), and plan service (customer service and overall rating of health plan).

So far, the data available is based on historical performance of commercial and Medicare plans. Covered CA will soon have information on the experience of Covered CA enrollees available. California is the only state-based marketplace collecting and publicly reporting QRS information, which will allow enrollees to use this information to make thoughtful plan choices. Going forward, the survey will be done in multiple languages and CMS is beta testing a question about language and cultural competency.

Advocates encouraged Covered California to incorporate into the quality rating system the ability to stratify quality rating data by language, race/ethnicity, and income, which would help us better understand whether health plans are addressing the needs of vulnerable communities.

Essential community provider (ECP) status and access to care in vulnerable communities

An Essential Community Provider (ECP) is a health care provider that serves high-risk, special needs, and underserved individuals. Covered California wants to ensure that enrollees living in underserved communities by making sure provider networks match where enrollees live by zip code. Using enrollee data, Covered California has been able to identify the zip codes of the highest concentration of Covered California enrollees and map access to primary care, community clinics, health services, clean water, grocery stores, etc. This information can help link vulnerable community zip codes to crucial services. Covered California is also using this information to work with health plans to improve provider networks in these communities.

Health Access is pleased to see progress toward mapping health-related indicators at the zip code level. Income is only one social determinant of health. Race, ethnicity, language spoken, and other factors are considered. CC can play an important role in supporting and building provider capacity in underserved areas.

New Guidelines for Navigator Grants

The Covered CA board approved new guidelines for navigator grants. There will be no changes to entities eligible to participate in the Navigator Program. They are moving to a block grant model with payments made every 2 months. The block grants will allow organizations to better plan their own budget and staffing needs. This approach also recognizes the work of not just enrollment but outreach, education, and retention. The new grant model will hold organizations accountable through performance thresholds for new enrollments and renewals, which will help to determine future funding level and continued participation. The navigator grant will also be administered through a three-year contract term. Existing grantees will need to re-apply, and applications will be available next week. Covered California is looking for organizations that have an existing presence and established, trusted relationship with consumers in their community. They anticipate awarding grants in the amount of $50,000-$500,000.

Regulations

The board took action on regulations relating to Certified Application Enrollment Counselor and Individual Eligibility and Enrollment. Information about these regulations can be found here: